Course Number and Name Student Date Instructor Course Patient Initial Unit/ Room# DOB Code Status Height/Weight Allergies Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations History of Present Illness & Chief Complaint: Admission Diagnosis: Admitting dx: Left intertrochanteric hip fracture, pain Explain what a left hip fracture is GENERAL: HEENT: CHEST: HEART: LUNGS: ABDOMEN: PELVIS:. UPPER EXTS: LOWER EXTS NEUROLOGIC: SKIN: Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Diagnostic testing: abnormal Left hip xray Labs: Hematology: Hb 14, HCT 42, Platelets 195, WBC 8, RBC 4.3 -all within normal range Electrolytes: K+ 3.8, Na 142, Creatnine 0.8, Cl- 101, BUN 20, HCO3- 24, Calcium total 8.6 -all within normal range Past Medical (Pathophysiology of medical diagnoses): Surgical History: Medical hx: Diagnosed with osteoporosis 10 years ago in 2011 Explain pathopysiolgy of osteoporosis Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Religion: Christian Social background: White, female, English speaker, widowed, mother of 1 daughter, lives with daughter - Concerns: -depression - need of assistance at home - Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations At risk for: loss of physical function - perform active range of motion 2 a day - - Rick for skin integrity - Consults/ discharge referrals: Orthopedic consult, physical therapy, social worker Orders: take pain medication prn Diet: n/a Signs and Symptoms As evidenced by Related to Contributing Factors Diagnostic Label Priority Nursing Diagnosis (at least 2) Written in three part statement Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation Goal Met, Partially Met, or Not Met & Expl ...

1. Course Number and Name
Student
Date
Instructor
Course
Patient Initial
Unit/ Room#
DOB
Code Status
Height/Weight
Allergies
Temp (C/F Site)
Pulse (Site)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
Pain Scale 1-10

2. History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence
Based Citations
Physical Assessment Findings including presenting signs and
symptoms supported with Evidence Based Citations
History of Present Illness & Chief Complaint:
Admission Diagnosis:
Admitting dx: Left intertrochanteric hip fracture, pain
Explain what a left hip fracture is
GENERAL:
HEENT:
CHEST:
HEART:
LUNGS:
ABDOMEN:

3. PELVIS:.
UPPER EXTS:
LOWER EXTS
NEUROLOGIC:
SKIN:
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/
Values (with normal ranges),
include dates and rationales supported with Evidence Based
Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
Diagnostic testing: abnormal Left hip xray
Labs:
Hematology: Hb 14, HCT 42, Platelets 195, WBC 8, RBC 4.3
-all within normal range
Electrolytes: K+ 3.8, Na 142, Creatnine 0.8, Cl- 101, BUN 20,
HCO3- 24, Calcium total 8.6
-all within normal range
Past Medical (Pathophysiology of medical diagnoses):
Surgical History:
Medical hx: Diagnosed with osteoporosis 10 years ago in 2011
Explain pathopysiolgy of osteoporosis
Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations
Socioeconomic/Cultural/Spiritual Orientation

4. & Psychosocial Considerations/Concerns (3) supported with
Evidence Based Citations
Religion: Christian
Social background: White, female, English speaker, widowed,
mother of 1 daughter, lives with daughter
-
Concerns:
-depression
- need of assistance at home
-
Potential Health Deviations, Predisposing & Related Factors;
(At least two) Include three independent nursing interventions
for each
(“At Risk for…” nursing dx)
Inter-professional Consults, Discharge Referrals, & Current
Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations
At risk for: loss of physical function
- perform active range of motion 2 a day
-
-
Rick for skin integrity
-
Consults/ discharge referrals: Orthopedic consult, physical
therapy, social worker
Orders: take pain medication prn
Diet: n/a

5. Signs and
Symptoms
As evidenced by
Related to
Contributing
Factors
Diagnostic
Label
Priority Nursing Diagnosis
(at least 2)
Written in three part statement
Planning
(outcome/goal)
Measureable goal during your shift
(at least 1 per Nursing diagnosis)
Prioritized Independent and collaborative nursing interventions;
include further assessment, intervention and teaching
(at least 4 per goal)
Rationale Each must be
supported with Evidence Based Citations
Evaluation
Goal Met, Partially Met,
or Not Met
& Explanation
impaired physical mobility related to ROM
1.
2.

6. 3.
4.
1.
2.
3.
4.
Risk for pressure ulcer

7. MEDICATION LIST
Medications (with APA citations
Class/Purpose
Route
Frequency
Dose (& range)
If out of range, why?
Mechanism of action
Onset of action
Common side effects
Nursing considerations
specific to this patient
Enoxaparin sodiumAnticoagulants
subcutaneous
daily
40

8. Docusate sodiumLaxatives, Stool Softener
oral
daily
100
Morphin
Opiate, narcotic
IV
PRN every 4 hrs
4

9. Revision Date: Month, Year (i.e. February, 2010) Page 1
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